Professionalism and patient education in urologic surgery

Medical professionalism provides the guidelines that govern the patient-physician relationship. This implicit contract requires that patients be informed before making decisions regarding their medical care. Educating patients about diagnostic and treatment decisions is critical to an informed decision-making process. Shared decision-making is a recent paradigm shift in patient education that allows patients to make decisions based both on the counsel of their physicians and according to their own preferences and values. This approach moves away from previous models that focused on physicians or third-party payers as the arbiters of diagnostic and treatment choices. Urologic surgeons have been at the forefront of shared decision-making research and continue to promote this concept in the most recent American Urological Association Guideline on Detection of Prostate Cancer. Unfortunately, the fee-for-service financial structure that predominates in the United States’ health care system provides a disincentive for shared decision-making. By promoting patient volume rather than time spent with patients, this system rewards physicians who spend less time educating patients about diagnostic and treatment options. Therefore, to promote adherence to the educational responsibility inherent in medical professionalism, we recommend physician payment reform that rewards physicians for time spent with patients rather than the volume of patients seen.

Potential of metastin and metastin receptor as biomarkers for urological cancers

AIM: To investigate the current state of the research of metastin and metastin receptor in the urological cancer field.

METHODS: For analyzing the value of metastin and metastin receptor as molecular biomarkers for the patients with urological cancer, MEDLINE database searches were performed using these terms: metastin, KISS1, kisspeptin, renal (cell) carcinoma (RCC), kidney cancer or urothelial cancer or bladder cancer or prostate cancer or testicular cancer (tumor). Since the articles were evaluated by the validity of the articles based on plausibility, credibility, and evidence levels, the articles were graded according to their level of evidence, using the grading system defined by the Oxford Centre for Evidence-based Medicine.

RESULTS: A total of six clinical studies published by individual institutions between 2003 and 2013 were included in this review. The article numbers for each of the evidence levels 2a and 2b were three (50%) and three (50%), respectively. Immunohistochemistry and reverse transcriptase-polymerase chain reaction using tumor tissues were performed to analyze in five articles (83%) and in one article (17%). The value of metastin and/or metastin receptor as molecular biomarkers in clear cell RCC, upper tract urothelial carcinoma, and bladder cancer was evaluated by multivariate analysis. Low expression of metastin receptor in clear cell RCC and low expression of metastin in upper tract urothelial carcinoma were significant risk factors for metastasis, and low metastin expression was an independent prognostic factor in bladder cancer.

CONCLUSION: Metastin and metastin receptor have potential as suitable molecular biomarkers for urological cancers. However, future studies of metastin and metastin receptor should undergo external validation to ensure consistency across different patient series, since individual institutional studies lack generalization.

Extraperitoneal robot-assisted radical prostatectomy: Comparison with transperitoneal technique

AIM: To determine peri-operative, oncological, functional and safety profiles of extraperitoneal robot-assisted radical prostatectomy (eRARP) vs transperitoneal robot-assisted radical prostatectomy (tRARP) in a single centre.

METHODS: A total of 120 consecutive patients underwent 50 eRARP and 70 eRARP operations respectively by the same surgical team. Peri-operative and post-operative outcomes including blood loss, hospitalization, complications (Clavien grade), positive surgical margin (PSM) rates, continence and erectile function were compared. The performance of eRARP required several technical modifications. These included development of Retzius’ space by balloon insufflation, laparoscopic dissection of lateral extensions of this area; caudal port positioning; cranial digital stripping of peritoneum for sucker port and lodging the bagged prostate specimen adjacent to the lateral assistant port to permit space for urethro-vesical anastomosis.

RESULTS: Robotic console times were shorter with eRARP vs tRARP (145.1 min vs 198.3 min, P < 0.0001). There were no significant differences in blood loss, PSM rates (eRARP 17.7% vs tRARP 22%) or complications (eRARP 8.5% vs tRARP 8%). A drain was used in all patients after tRARP and in 25/70 eRARP cases. Length of hospital stay was shorter after eRARP (mean 1.94 d vs 3.6 d, P < 0.0002). There were no differences between techniques in continence or potency at 6 mo. eRARP required several technical modifications: development of Retzius’ space by balloon insufflation, laparoscopic dissection of lateral extensions of this area; caudal port positioning; and lodging the bagged prostate specimen adjacent to the lateral assistant port to permit space for urethro-vesical anastomosis.

CONCLUSION: eRARP demonstrated advantages in surgical times, hospital stay and equivalence in PSM rates, complications and functional outcomes. eRARP is a useful alternative to tRARP especially in patients with adhesions, pre-existing inguinal hernias, or those unable to withstand steep Trendelenburg position.

Is verumontanum resection needed in transurethral resection of the prostate?

Transurethral resection of the prostate is the mainstay for treatment of bladder outflow obstruction. It is a procedure that involves various complications and has a high success rate. In view of a recent publication presenting the effect of verumontanum resection on functional outcome and possible complications after TURP, the present manuscript presents the available evidence on the subject as well as the possible criticism about the technique suggested by the authors. The results available do not confirm that by resecting the verumontanum there is a clinically significant improvement in the functional outcome, however confirm that continence is not affected. The criticism probably lies in the fact that resecting such a small amount of tissue like the verumontanum (its size probably remains the same with few changes during lifetime) probably does not affect outcome, yet the resection of hyperplastic apical tissue around it may play a role in functional improvement.

What is the purpose of launching World Journal of Clinical Urology?

The first issue of the World Journal of Clinical Urology (WJCU), whose preparatory work was initiated on December 6, 2010, will be published on December 28, 2011. The WJCU Editorial Board has now been established and consists of 101 distinguished experts from 25 countries. Our purpose in launching the WJCU is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.

What is the purpose of launching World Journal of Clinical Urology?

The first issue of the World Journal of Clinical Urology (WJCU), whose preparatory work was initiated on December 6, 2010, will be published on December 28, 2011. The WJCU Editorial Board has now been established and consists of 101 distinguished experts from 25 countries. Our purpose in launching the WJCU is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.